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Guidance for Properly Reporting Modifier -33

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The following was written by Sumit Gandhi, CPC, associate vice-president of medical coding for GENASCIS.

The AMA announced the new CPT modifier - 33 during the Nov. 2010 CPT Symposium. It is not included in the 2011 CPT manual. This modifier is related to mandated preventive services performed in order to comply with the Affordable Care Act, and this is how it reads:

33 – Preventive Service: When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

What this means to coders

The application of modifier -33 is primarily to indicate the impact on patient's co-pay, deductible, etc., with such services and has less relevance to the coding itself. To quite a degree, this modifier is a commercial payor's replacement to Medicare's -PT modifier with the difference being -PT is only applicable when a planned screening colonoscopy turned out to be a therapeutic one, whereas modifier -33 is for any such procedure/service that was planned to be "preventive" and didn't turn out so.

How to report

Scenario for modifier -33

Patient seen for follow-up for hypertension, the provider issues a lab referral for cholesterol screening (preventative service). Modifier -33 is attached to the lab CPT code for the cholesterol screening. ICD-9 code V77.91 (screening for lipoid disorders) is coded as an additional diagnosis. Modifier -33 is not required on services that are inherent to screening services, i.e., screening mammography.

Scenario for modifier -PT

A Medicare patient presents for a screening colonoscopy with a history that a polyp was removed three years ago. The patient has no current signs or symptoms. This patient's encounter is coded history of colon polyps (ICD-9 code V12.72) and screening colonoscopy on an individual at high risk (HCPCS G0105). During the screening exam, the physician discovers a polyp in the sigmoid colon and removes it with a snare technique. Based on the definition of and requirements for modifier -PT, the correct code assignment for this exam is 45385-PT.

The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.